Medical Oxygen Supply During COVID-19: A Study with Specific Reference to State of Andhra Pradesh, India.

Optimal medical infrastructure utilization became a high priority for Governments worldwide during the COVID-19 pandemic. Special attention is drawn to both the import and local manufacture of medical oxygen gas to ensure its uninterrupted supply to designated COVID-hospitals identified by the local administration. The paper apprises on the administrative and regulatory orders to control the supply and transportation of medical oxygen gas by examining its implementation in India in general and the State of Andhra Pradesh in particular. The paper enhances understanding of the working of governmental administrative systems amidst the emergency. The observations and findings from the research work can be vital inputs to Governmental institutions, regulatory bodies, the industry, and various other stakeholders dealing with medical oxygen gas so that policy and process flow can be improvised.

Introduction

Governments across the world attended medical emergencies triggered by the COVID-19 pandemic. Like several other countries, India, the second-most populous country, battled for optimal usage of medical infrastructures, such as hospital beds, medical oxygen, and others [1]. This pandemic required different kinds of facility to handle patients from distance [2] while prediction of lockdown period also had importance as discussed [3].

Apart from its industrial usage, oxygen is used for various medical purposes - from general medicine administration to medical assistance and emergency procedures. Oxygen is a critical element for human life existence, and because of its natural availability through the air, it is sometimes forgotten to be a life-saving essential medicine. The timely availability of medical oxygen is a decider of life and death for the patient. Hospitals are always giving priority over the rest regarding the continuous availability of medical oxygen. Medical Oxygen is a critical ingredient in treating certain critical health conditions such as pneumonia, malaria, sepsis, and meningitis. Children and mothers are often administered medical oxygen to ease breathing when their lives are at risk during medical treatment. Its importance once grew more during the COVID-19 pandemic because of its close association with the respiratory system [4]. High-flow nasal oxygen is found to be a safe and efficient treatment for COVID-19 patients who are not in an ICU [5]. The WHO says that 15 percent of COVID-19 patients require medical oxygen because of breathing difficulties [6]. Silent hypoxia patients do not show any evident respiratory distress but experience sudden dangerously low oxygen levels [7]. NIH recommends high-flow nasal cannula (HFNC) oxygen over non-invasive positive pressure ventilation (NIPPV) [8]. Some critically ill patients even require a ventilator. However, the available number of ventilators is too low. This forced medical equipment manufacturers to quickly go into production mode.

COVID-19 clearly exposed a major weakness in the health systems – that of medical oxygen production and delivery [9]. Despite administrations trying to do their best to supply medical oxygen, demand overtook the supply, making its availability inadequate during the pandemic times. Some modern methods, such as on-site medical oxygen production using oxygen generators, are experimented. Such setup enables continuous, reliable, and cost-effective supply for mobile and static medicine. They are specially designed and developed to supply oxygen in medical facilities following strict quality guidelines. These generators meet global quality standards and provide purity of 93 to 95 percent. Thanks to Industry 4.0 standards, remote monitoring, and operation of the medical oxygen generation systems can be done from a computer workstation, tablet, or smartphone from anywhere in the world [10]. Smart factories can help in optimizing the compressor room practices at the manufacturing unit [9].

Hospitals procure medical oxygen through cylinders that fill it at industrial gas plants. The cylinders are installed in the hospital basement or at proximity and piped to the patient's bed. The patients are charged based on consumption. Typically, a $40–$60 would be charged for a severe pneumonia child who spends 3–4 days and consumers 4,000 to 8,000 cubic liters of oxygen. The challenge for medical and health administration is to increase the supply of medical oxygen while reducing cost so that it is accessible where it is needed most, free at the point of use. This demands increased investment and commitment to put oxygen infrastructure at the centre of universal health coverage strategies [4].

Most of the COVID beds in hospitals worldwide faced a sudden demand for piped oxygen supply forcing hospital administrations to spend more to supply copper piped oxygen connected to a cylinder bank.

The global supply of oxygen is in the hands of relatively few corporates [11]. As much as 80 percent of the supply is through a handful number of suppliers. The market size which was just about $5 billion in 2019 is forecasted to become a $8 billion market by 2026. Due to the panic requirement, industrial oxygen cylinders are ordered to convert into medical oxygen, and orders were placed for more cylinders. The situation necessitated more non-budgetary spending by hospitals.

Experiment

Objectives of the study

Key objectives of the study are:

to apprise on the sudden demand for medical oxygen gas that arose during the pandemic situation.

understand the coordination of various stakeholders such as the Governments, oxygen suppliers, and hospitals during the sudden situation.

Research methodology

Data from secondary sources such as authoritative websites (WHO amongst others), hospitals, medical equipment providers, oxygen providers, government bodies, regulators, media, and research journals are collected and reported in this study.

Results and discussion

The Petroleum and Explosives Safety Organization (PESO) is the body that safety in manufacturing/refining, storage, transportation, handling, and use of hazardous substances [12]. It runs under the Department of Promotion of Industry and Internal Trade of the Ministry of Commerce & Industries of the Indian Government. In 2020, PESO announced a series of new/amendments to several rules and notifications to foster the quick and safe transport of medical oxygen gas. During the pandemic times, the Central Government and PESO were in constant coordination with the State Government units (such as the District Collectorates, the Drug Control Administration (DCA), amongst others). These local units, in-turn, have set up a coordination system at the District Level. Owing to increased reports of malpractices, PESO issued orders insisting on maintaining the day-to-day record of filling, storage, and dispatch of cylinders and submitting reports.

The District Collectors at the District level are empowered to make individual decisions such as preparing supply schedules, thereby rationalizing the supply of cylinders to various locations and hospitals according to priority and urgency. While the authorities prepared the supply schedules, the end customer (such as hospitals) would be paying the bill. Oxygen data availability status reports from various oxygen suppliers are updated daily to the District authority, who in-turn synchronizes at the state-level.

The Center for Global Development (CGD) highlighted the need for a balance in immediate needs with long-term cost-effectiveness due to an increase in oxygen demands due to COVID-19. The note provided considerations for setting up liquid oxygen tanks, PSA oxygen plants, oxygen cylinders, and oxygen concentrators [14]. Having drawn from China's experiences, even the WHO gave similar interim guidance regarding oxygen sources and distribution for treatment centers [13]. Owing to the pandemic, oxygen manufacturing infrastructure for industrial use was diverted for medical purposes. This negatively impacted the supply and availability of gas for iron and steel cutting, thermal plants, and railway track projects. However, the option might be necessary owing to the medical emergency.

Cryogenic Distillation Plants that use liquid oxygen can get above 99.5 percent pure oxygen, while the oxygen generation plant uses air, compresses it, and purifies it to extract 93 percent oxygen. Looking at the oxygen demand, the Central Government took up the onus of procuring oxygen cylinders during the pandemic's early stages and distributed them to states. The rules governing the import of liquid oxygen from other countries were liberalized. Separately, owing to the emergency situation, the approval of ISO Tank Container for domestic movement facilitates the fast and safe movement of liquid oxygen in the country. Stakeholders desirous to import/transport liquid oxygen in ISO Tank Container are allowed to submit Application Form in AS-4, and approval within 48 h was granted. Permissions and Generated Standard Operating Procedures (SOP) were given to convert industrial oxygen cylinders and even non-toxic, non-flammable cylinders to store and supply medicinal oxygen. Hospitals were allowed to install cryogenic liquid tankers so that liquid oxygen (that is less bulky) can be used, thereby reducing the waiting time for oxygen gas cylinder suppliers to replenish. Hospitals undoubtedly understood the need for investing and installing cylinders and tankers. Of course, this investment is not merely for COVID usage but will remain a worthy infrastructure investment for the hospital. Even certain provisions of the Motor Vehicles Act, 1988 are relaxed for transport vehicles that will be used exclusively for the carriage of oxygen during COVID-19 up to March 31, 2021 [15].

Despite mid-October 2020, the demand levels for medical oxygen gas and the number of patients requiring medical oxygen gas have shown no signs of slowing down. However, there was a geographic shift in demand. During the pandemic's peak, states such as Punjab, for example, have sought liquid oxygen supplies from neighbors such as Himachal Pradesh and Uttarakhand [17]. Meanwhile, various districts in the state of Maharashtra have already set up their oxygen plants. Others went into the administrative clearance processes for setting up shortly. As many as 14 districts have set up their plants while 16 other districts have called for tenders for setting them. The state has two major suppliers - Inox Air Products (four plants at Raigad, Pune, and Nagpur) and Linde India (two plants at Raigad and Thane) with a combined 800 metric ton liquid capacity oxygen every day. Corporates with in-house oxygen manufacturing facilities, such as JSW Steel's Mangaon facility in Pune, came forward to provide oxygen for hospitals that needed it.

Further, the Government directed the Electricity Department not to cut power supply for oxygen manufacture plants. Some districts (such as Latur and Beed) had to cut inter-district transportation of oxygen gas as the district themselves needed it [16]. Madhya Pradesh has cut off the oxygen supply for factories and diverted it for medical purposes. North India began to report a higher number of cases at later part compared to Middle and South India. The dynamics are opposite in the early stages of the pandemic. The shift in demand levels required the transfer of liquid cryogenic tankers and cylinders to be moved from states with lesser demand than those needing more. The Central Government took up all the coordination activity and allowed the states to help each other. The Government alerted the All-India Industrial Gases Manufacturers' Association (AIIGMA) that Liquid Medical Oxygen being sold as Industrial Oxygen after paying 12 percent GST. The act is illegal, unethical, and a loss to the exchequer.

The various stages in the oxygen supply process were explained in Fig. 1 .

Fig 1

Flowchart explaining the stages of the Oxygen supply process.

Findings

Double the consumption of medical oxygen is observed in Andhra Pradesh owing to COVID-19 patient support at Hospitals and at designated COVID Care Centres (Fig 2, Fig 3 ).

Fig 2

Monthly oxygen supply in various districts of Andhra Pradesh during COVID-19.

Fig 3

Month-wise oxygen supply in the State of Andhra Pradesh during COVID-19.

Large Government fund supported hospitals, such as the King George Hospital (KGH), Visakhapatnam, installed a 13 KL liquid oxygen storage tank to augment their capacity. Other smaller Government and Private hospitals installed liquid oxygen storage tanks sizes ranging from 1 KL to 10 KL.

The usual demand for medical oxygen in Andhra Pradesh is around 15–18 lakh cubic meters, according to Andhra Pradesh Drug Control Administration (APDCA). At its peak (in August 2020), 80 lakh cubic meters' highest demand was observed. The average distributor supply to all Government and private hospitals is at 460 cylinders/day. A usual distributor alone used to supply close to 250 cylinders a day in Visakhapatnam.

A Visakhapatnam-based medical oxygen producer observes the highest supply of 2,348 cylinders/day. The cylinders are made available to hospitals in and around Visakhapatnam.

Suggestions

Oxygen production in the State: Oxygen is an essential drug, and few vendors in India are allowed to produce it. The oxygen production process concentration with few manufacturers has resulted in cost escalations and an irrational supply of Oxygen gas. To have a fair market play, State Governments should encourage investment in the sector. Populous states such as Uttar Pradesh, for example, can set up oxygen units – one each in Western, Central, and the Eastern Uttar Pradesh. Other states can use the surplus capacity from these units.

Expertise in oxygen manufacture and supply expertise makes an enormous difference. Hence, existing medical oxygen suppliers having safe and timely supply practices should be encouraged.

Assessment of Oxygen gas Supply system: Most district-level hospitals do not have piped medical gas systems. Despite their heavy consumption, many district hospitals, even larger cities, have a single cylinder. Need assessment for uninterrupted oxygen supply system is necessary at all district-level hospitals. Such an assessment should be done at least every five years or at an interval as decided by the health department to address demand and technology changes.

Establishing Oxygen demand analysis and procurement system: Each district hospital should have a system of assessing/forecasting Oxygen gas requirements. Such an assessment should include monthly or seasonal variations in oxygen consumption. A review should also include the medical gas supplier's performance, and the District hospital should use such information for the procurement of medical gas.

Oxygen monitoring system: Most district hospitals are ill-equipped to monitor uninterrupted oxygen supply resulting in unwanted casualties at the critical care areas. An effective alarm system-based monitoring system is necessary to supervise the oxygen supply in different hospital areas, especially in critical care areas, to address oxygen supply shortages.

Conclusion

The Covid-19 increased the problems to heart patient [18] that related with the many other factors. On the other hand, all the infected people may cured by sufficient facilities. In these facilities, oxygen is a technology-dependent medicine and requires effective teamwork between healthcare workers, technicians, and managers. Improving oxygen systems is an achievable priority for hospitals in LMICs. This paper proposes practical steps to support significant and sustainable improvements in hospital oxygen systems during the COVID-19 pandemic. Hospital administration and policymakers can derive learnings from this paper to take immediate steps toward better oxygen access to patients.

However, biomedical engineers and hospital technicians are frequently left out of decision-making processes citing, often citing lack of maintenance budgets or system support. Training, provision of tools and spare parts, and more robust maintenance and transport systems can enable repair and optimization of existing oxygen equipment and supply chains. Installation of simple piping and individual flowmeters can improve safety (allowing individual titration of flow), efficiency (sharing a single oxygen source between multiple patients), and infection control (by keeping sources farther from patient areas). Including technicians alongside health care workers in multidisciplinary teams can help transform a problem-driven “oxygen headache” into focused oxygen solutions. We have created practical resources to assist biomedical engineers/technicians in building and maintaining reliable, user-friendly oxygen systems using oxygen concentrators, cylinders, flowmeter instruments/accessories, and simple piping. Improving patient outcomes always hinges on doing the basics well. The COVID-19 pandemic offers the opportunity to refocus efforts on the basics of acute care, knowing that improvements in oxygen (and infection control, triage, laboratory testing, amongst others) will benefit patients both now and in the future.

CRediT authorship contribution statement

Srinivas Bikkina: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing - original draft. Vijaya Kittu Manda: Writing - review & editing. U.V. Adinarayana Rao: Project administration, Supervision.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.